1. The Association of Medical Microbiologists
is a professional body concerned with all aspects of medical microbiology
and infection in the United Kingdom. It provides a UK network
involving over 500 senior members of the profession from university
departments of medical microbiology, the Public Health Laboratory
Service, National Health Service departments and the Armed Forces.

1.1. The first object of surveillance must
be to provide a health benefit and we would see its role as:

1.1.1. the detection of outbreaks;

1.1.2. the detection of new, emerging and
re emerging conditions which will include those due to bio terrorism
and bio crime;

1.1.3. health-care planning, to include
the formation of policies, guidelines and codes of practice; and

1.1.4. providing measures of performance
and assessment of outcome.

2. THE PROBLEMSWITH SURVEILLANCEINTHE
UNITED KINGDOM

2.1. Importance of accurate microbiological
confirmation

2.1.1. It should be noted that laboratory
confirmed microbiological evidence is the only accurate representation
of the true status of contagious disease. Although clinical diagnosis
does provide an immediacy it is only in a small number of diseases
that sensitivity and specificity of diagnosis would be reliable.
The network of microbiology laboratories feeding significant isolates
to specialist centres for typing and data for collation and epidemiology,
would provide the most appropriate and durable system of epidemiological
intelligence. It is also true that certain diseases for which
a microbial aetiology is suspected but not yet proven, such as
Kawasaki's disease can only be diagnosed clinically. A truly catholic
surveillance programme would need to include such diseases.

2.1.2. There are areas where insufficient
care is made in the accuracy of diagnosis, measles is now a clinically
difficult disease to diagnose and is not always confirmed by the
laboratory. In some areas where clinical diagnosis is difficult
there are insufficiently sensitive laboratory techniques available,
pertussis is an example. It may be justified to have "spotter"
primary care practices, who are tasked with providing additional
and more intensive microbial surveillance as opposed to just clinical
diagnosis.

2.1.3. There is a need for standardisation
both in the range of pathogens detected and in the methods employed.
It is probably a requirement that the methodology employed in
diagnostic laboratories should not only conform to accepted standards
for the United Kingdom but also internationally. The area of antimicrobial
sensitivity testing is an area where international standards should
be applied.

2.1.4. Once, when there was a sense of community
and there existed District General Hospitals, the local Microbiologist
felt a responsibility for the welfare of the local population.
The purchaser-provider split has tended to divorce hospitals from
their population. Creating a team (microbiologists, family practitioners
and public health professionals) that can recognise a local need
would add meaning and contribute to the accuracy of surveillance.

3. PERSONNEL
INVOLVEDIN
SURVEILLANCE

3.1. A wide range of health-care personnel
are involved in providing surveillance (clinicians, public health
doctors, general practitioners, sexual health clinics). One of
the tasks will be to extend the role of clinicians working in
areas not traditionally involved in gathering data for microbial
diseases, the accident and emergency and intensive care departments
may be important for sentinel detection of bio terrorism.

3.2. The existing United Kingdom network
of microbiology laboratories, which includes the NHS and PHLS
networks has been feeding information centrally for several decades
but with only patchy engagement. The current task is to make the
collection of epidemiologically important information more inclusive
and to ensure that the information held within the data set is
used appropriately and distributed widely. This must be achieved
within the manpower shortages that exist within the pathology
services. It would be advisable to look at the skill mix of personnel
currently involved in the collection of this information. For
example, infection control is largely provided by medical and
nursing staff, however the first call on these personnel is often
the control of outbreaks and the care of the individual patient.
Biomedical scientists and information technology staff should
have an increased part to play in the infection team, their roles
being more dedicated to the processing of epidemiologically important
information.

3.3. The single major message must be that
surveillance should be an integral part in the function of many
health-care professionals and that methods must be found to integrate
this task into the work pattern and to ensure that it causes no
additional burden. The answer almost certainly lies within improved
information technology.

4. INFORMATION
TECHNOLOGY ISSUES

4.1. Probably the single most important
task in enabling the flow of data centrally to the Communicable
Disease Surveillance Centre would be changes to the information
technology agenda. Where previous attempts at inclusiveness have
fallen short, was the requirement to add information manually
to the data set. Many laboratories found that they had insufficient
resource to enhance the data. Given the shortages of staff and
insufficient funding provided to diagnostic microbiology laboratories,
the task of transmission of epidemiology data centrally must be
both simple and automatic. Only information collected by laboratory
information systems can be reliably forwarded. There is no standardisation
for these systems with regard to a minimal data set for epidemiological
and surveillance purposes. The sending of electronic pathology
messages has not, in the field of infection, been crowned with
success. Schemes such as the Reed coding system have not been
a success in this area, we are aware of initiatives being undertaken
within the NHS and priority must be given to the successful coding
of epidemiologically important data. All previous attempts seem
to have concentrated on the coding of numerical data ie haematology
and clinical chemistry, probably because this problem was most
easily solved.

4.2. For information technology to benefit
surveillance the following points are absolute requirements:

4.2.1. there must be standardisation of
data captured during the requesting of the clinical microbiology
investigation and this should include epidemiological information
where appropriate;

4.2.2. the NHS messaging systems need to
be improved to allow a standardised infection/epidemiology message
to be sent;

4.2.3. only data captured automatically
in the above systems should be part of the surveillance output;
and

4.2.4. data storage systems must be more
highly developed to include information necessary for different
surveillance systems. Information required for surveillance of
hospital-acquired infections will require more complex coding
of untoward events and complications. Epidemiological information
on community infections will require linking to immunisation and
general practice records. The surveillance of antimicrobial resistance
will need linking to primary care and hospital prescribing information.
The combining of all these data systems into the health record
would provide an immensely powerful tool for surveillance.

5. SURVEILLANCEATTHE
CLINICAL INTERFACE

5.1. All health-care systems require surveillance,
both for predicting the needs of the population and to monitor
outcomes of treatment. In an ideal system of surveillance data
capture would be embedded within the process and function of clinical
care. We currently face the problem of inadequate engagement of
clinical staff within the process. There are certainly areas where
we believe that targeted surveillance would improve outcomes.
An example of this would be orthopaedic hip and knee surgery.
Reliable diagnosis of the infective complications is not necessarily
an easy task and requires significant clinical input. It is not
yet clear what is the appropriate skill mix for performing surveillance
of surgical site infection. It is likely that the clinical team
will need augmentation, probably from the infection control team,
to provide logistic support and an element of quality assurance.
Clinical microbiology has so far driven this process but lacks
the appropriate manpower resource and possibly training to complete
this cycle. Expansion of targeted surveillance, even if microbiology
was to take only a supervisory and educational role, rather than
the current executive function, would not be possible within the
available manpower structures.

6. IMPROVEMENTSIN DIAGNOSISAND PREVENTION

6.1. There are other areas of communicable
disease where we believe that surveillance requires enhancement.
The aetiological diagnosis of respiratory tract infection is inadequate,
the newer anti-viral treatments require the positive identification
of the pathogen before treatment is started, this is well indicated
with the recent introduction of newer agents active against influenza
virus. Greater investment in molecular diagnostic methods must
be made before such advances in the treatment of the population
can be reliably and efficiently introduced. Similarly there has
been a failure to adequately research the area of prevention by
immunisation. Outstanding examples are the lack of vaccines for
the sexually transmitted diseases and the poor performance of
those that exist for the prevention of tuberculosis.

7. POSSIBLE SHORTCOMINGSOF GAC

7.1. One of the transparent omissions within
"Getting Ahead of the Curve" is the failure to address
the issue of surveillance of community acquired infections post
the establishment of the Health Protection Agency. There is a
lack of reassurance that resources currently expended on surveillance
of communicable disease by PHLS laboratories will be transferred
to NHS laboratories, and that all microbiology laboratories will
receive additional funding to improve the surveillance of disease.
There are also concerns that the pace of change envisaged by "Getting
Ahead of the Curve" will lead to the removal of one network
before new NHS networks are in place. It is also not clear whether
the different models envisaged in the current pathology modernisation
schemes are appropriate for microbiology. Whilst it is highly
desirable that microbiology should be part of an integrated pathology
unit at trust level, the most appropriate network for microbiology
laboratories could require a degree of separation.